﻿<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
    <title></title>
    <style type="text/css">
        .style1
        {
            width: 105px;
        }
        #Text1
        {
            width: 40px;
        }
        #Text2
        {
            width: 40px;
            height: 22px;
        }
        #Text3
        {
            width: 40px;
        }
        #Text4
        {
            width: 40px;
        }
        #Text5
        {
            width: 40px;
        }
        #Text6
        {
            width: 40px;
        }
        .style2
        {
            width: 588px;
        }
        #selectAge
        {
            width: 98px;
        }
        #Text7
        {
            height: 100px;
            width: 500px;
        }
        #Text8
        {
            width: 500px;
            height: 57px;
        }
        #Submit1
        {
            text-align: center;
        }
        #Text9
        {
            width: 36px;
        }
        #Text10
        {
            width: 36px;
        }
        .style3
        {
            width: 105px;
            height: 120px;
        }
        .style4
        {
            width: 588px;
            height: 120px;
        }
        .style5
        {
            height: 120px;
        }
        #Text11
        {
            width: 36px;
        }
        #Text12
        {
            width: 36px;
        }
        .style6
        {
            width: 50px;
        }
        #Text13
        {
            width: 40px;
        }
        #Text14
        {
            width: 40px;
        }
        #Text15
        {
            width: 40px;
        }
        #Text16
        {
            width: 40px;
        }
        #Text17
        {
            width: 40px;
        }
        .style7
        {
            width: 100px;
        }
        #Text18
        {
            width: 36px;
        }
        </style>
</head>
<body>
<form>
    <table style="width:100%;">
        <tr>
            <td class="style1">
                &nbsp;</td>
            <td class="style2">
                leave Period:</td>
            <td>
                &nbsp;</td>
  
        </tr>
        <tr>
            <td class="style1">
                <a href = "placeholder">
                    Placeholder
                </a>
                </td>
            <td class="style2">

                <table style="width:100%;">
                    <tr>
                        <td align="left" class="style6">
                            DD</td>
                        <td class="style6">
                            MM</td>
                        <td class="style6">
                            YYYY</td>
                                                    <td class="style7">
                                                        AM/PM</td>
                        <td>
                            To</td>
                        <td class="style6">
                            DD</td>
                                                    <td class="style6">
                                                        MM</td>
                        <td class="style6">
                            YYYY</td>
                        <td>
                            AM/PM</td>
                    </tr>
                    <tr>
                        <td class="style6">
                            <input id="Text1" align="middle" type="text" /></td>
                        <td class="style6">
                            <input id="Text13" align="middle" type="text" /></td>
                        <td class="style6">
                            <input id="Text14" align="middle" type="text" /></td>
                                                    <td class="style7">
                                                        <input id="Radio1" type="radio" name = "r1" /><input id="Radio2" type="radio" name = "r1" /></td>
                        <td>
                            &nbsp;</td>
                        <td class="style6">
                            <input id="Text15" align="middle" type="text" /></td>
                                                    <td class="style6">
                                                        <input id="Text16" align="middle" type="text" /></td>
                        <td class="style6">
                            <input id="Text17" align="middle" type="text" /></td>
                        <td>
                            <input id="Radio3" type="radio" name = "r2" /><input id="Radio4" type="radio" name = "r2"/></td>
                    </tr>

                </table>

                </td>

            <td>
                &nbsp;</td>

        </tr>
        <tr>
            <td class="style1">
                <a href = "placeholder">
                    Placeholder
                </a></td>
            <td class="style2">
                Leave Type       <select name="selectAge" id="selectAge">  
                                    <option value="1">Annual</option>  
                                    <option value="2">Medical</option>  
                                    <option value="3">Compensation</option>  
                                  </select> 
            </td>
            <td>
                &nbsp;</td>
        </tr>
        <tr>
            <td class="style3">
                 <a href = "placeholder">
                    Placeholder
                </a></td>
            <td class="style4">
                Reason<br />
                <input id="Text7" type="text" /></td>
            <td class="style5">
                Annual Leave<br />
                <input id="Text9" readonly="readonly" type="text" /> used
                <input id="Text10" readonly="readonly" type="text" /> Total<br />
                Medical Leave<br />
                <input id="Text11" readonly="readonly" type="text" /> used<br />
                Compensation<br />
                <input id="Text12" readonly="readonly" type="text" /> used
                <input id="Text18" readonly="readonly" type="text" /> Total</td>
        </tr>
        <tr>
            <td class="style1">
                &nbsp;</td>
            <td class="style2">
                Work Dissemination<br />
                <input id="Text8" type="text" /></td>
            <td>
                &nbsp;</td>
        </tr>
        <tr>
            <td class="style1">
                &nbsp;</td>
            <td class="style2">
                <input id="Submit1" align="middle" type="submit" value="Apply" /></td>
            <td>
                &nbsp;</td>
        </tr>
    </table>
</form>
</body>
</html>
